A Randomized Controlled Trial of the Therapeutic Workplace for Community Methadone Patients

1: Exp Clin Psychopharmacol. 2006 Aug;14(3):350-60. Links

A randomized controlled trial of the therapeutic workplace for community methadone patients: a partial failure to engage.

Knealing TW, Wong CJ, Diemer KN, Hampton J, Silverman K.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.

The Therapeutic Workplace is an employment-based treatment for drug addiction that uses wages for work to reinforce drug abstinence. The Therapeutic Workplace has promoted abstinence from heroin and cocaine in treatment-resistant mothers in methadone treatment. This study attempted to replicate that effect in crack cocaine users recruited from community-based methadone programs. Participants were randomly assigned to a Therapeutic Workplace (n=22) or usual care control (n=25) group. Therapeutic Workplace participants were invited to work in the workplace and earn vouchers every weekday for 9 months contingent on documented opiate and cocaine abstinence. The two groups did not differ significantly on measures of cocaine or opiate use collected during study participation. Daily attendance and urinalysis results of the Therapeutic Workplace group were analyzed, and only 7 of the 22 participants initiated consistent periods of abstinence and workplace attendance. Two individuals gained access to the workplace on a few days, and 9 participants attempted to gain access to the workplace but never provided a drug-negative urine sample. Possible reasons for differences between the current study and the previous Therapeutic Workplace study are considered. Procedures that increase participant contact with the Therapeutic Workplace and its reinforcement contingencies might increase the likelihood of these individuals being successful in the treatment program.

PMID: 16893278 [PubMed - indexed for MEDLINE

1: Subst Use Misuse. 2007;42(7):1127-40. Links

Establishing and maintaining job skills and professional behaviors in chronically unemployed drug abusers.

Wong CJ, Silverman K.

College of Medicine, University of Kentucky, Lexington, Kentucky 40536, USA. [email protected]

The therapeutic workplace intervention is an employment-based drug user intervention that integrates abstinence reinforcement contingencies into an employment setting, intended for individuals manifesting chronic unemployment and drug addiction. Research on the therapeutic workplace intervention has provided a unique and rare opportunity to collect data and conduct fine-grained analyses of the training and work performance of participants. Results from a series of studies document that chronically unemployed drug users display behaviors that likely limit their success in conventional businesses. This article reviews a systematic line of research showing that targeted and intensive contingency management interventions and training programs have been effective in promoting consistent attendance and high rates of productivity and establishing job skills for employment.

1: Psychol Bull. 1995 May;117(3):416-33. Links

Vocational rehabilitation of drug abusers.

Platt JJ.

Division of Addiction Research and Treatment, Medical College of Pennsylvania, Philadelphia 19102- 1192, USA.

Employment has been identified as an important element in the rehabilitation of drug abusers and, together with abstinence from illicit drugs and criminal involvement, is frequently used as a criterion of treatment outcome. The research literature for the last 20 years on variables affecting employment and the vocational rehabilitation of drug abusers is reviewed with an emphasis on (a) the identification of variables influencing the employment of drug abusers and (b) the evaluation results of interventions that have been developed for this purpose. It is concluded that a number of programs have been demonstrated to have had some success in the vocational rehabilitation of drug abusers. Specific recommendations are made concerning both the direction of further research in this area and the application of existing knowledge in current practice.

1: Exp Clin Psychopharmacol. 2002 Aug;10(3):228-40. Links

A reinforcement-based therapeutic workplace for the treatment of drug abuse: three-year abstinence outcomes.

Silverman K, Svikis D, Wong CJ, Hampton J, Stitzer ML, Bigelow GE.

Center for Learning and Health, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA. [email protected]

Long-term Therapeutic Workplace effects were evaluated in heroin- and cocaine- dependent, unemployed, treatment-resistant young mothers. Participants were paid to work or to train in the Therapeutic Workplace but had to provide drug-free urine samples to gain daily access. Participants (N = 40) were randomly assigned to a Therapeutic Workplace or usual care control group. Therapeutic Workplace participants could work for 3 years. Relative to controls, Therapeutic Workplace participants increased cocaine (28% vs. 54% negative; p = .04) and opiate (37% vs. 60% negative; p = .05) abstinence on the basis of monthly urine samples collected until 3 years after intake. The Therapeutic Workplace can be an effective long-term treatment of cocaine and heroin addiction in poor and chronically unemployed young mothers. 1: Subst Use Misuse. 2007;42(5):811-28. Links

An innovative job placement model for unemployed methadone patients: a randomized clinical trial.

Magura S, Blankertz L, Madison EM, Friedman E, Gomez A.

Institute for Treatment and Services Research at National Development and Research Institutes, New York, NY 10010, USA. [email protected]

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients -- the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. The study's limitations are noted. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed

1: J Appl Behav Anal. 2008 Winter;41(4):499-516. Links

Attendance rates in a workplace predict subsequent outcome of employment-based reinforcement of cocaine abstinence in methadone patients.

Donlin WD, Knealing TW, Needham M, Wong CJ, Silverman K.

Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.

This study assessed whether attendance rates in a workplace predicted subsequent outcome of employment-based reinforcement of cocaine abstinence. Unemployed adults in Baltimore methadone programs who used cocaine (N=111) could work in a workplace for 4 hr every weekday and earn $10.00 per hour in vouchers for 26 weeks. During an induction period, participants provided urine samples but could work independent of their urinalysis results. After the induction period, participants had to provide urinalysis evidence of cocaine abstinence to work and maintain maximum pay. A multiple regression analysis showed that induction period attendance was independently associated with urinalysis evidence of cocaine abstinence under the employment-based abstinence reinforcement contingency. Induction period attendance may measure the reinforcing value of employment and could be used to guide the improvement of employment-based abstinence reinforcement.

PMID: 19192855 [PubMed - indexed for MEDLINE]

PMCID: PMC2606606 [Available on 2009/06/01

: J Subst Abuse Treat. 2002 Dec;23(4):261-71. Links

The effect of treatment completion and length of stay on employment and crime in outpatient drug-free treatment.

Zarkin GA, Dunlap LJ, Bray JW, Wechsberg WM.

RTI, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. [email protected]

Length of stay in treatment has been found to be a significant predictor of positive post- treatment outcomes, such as decreases in unemployment and crime. However, length of stay may be an incomplete predictor of successful treatment. Surprisingly, few studies have examined whether completing treatment in addition to length of stay is an important factor in explaining positive treatment outcomes. The objective of our study is to examine the effect that treatment completion and length of stay have on post-treatment employment and crime for patients in outpatient drug-free treatment, the largest treatment modality in the United States. We use conditional logit and multiple regression models with program-level indicator variables (fixed effects) to estimate the effect of treatment completion and length of stay on employment and crime controlling for drug use severity, previous treatment history, and other patient demographics. Data are from the National Treatment Improvement Evaluation Study and include 986 adults enrolled in outpatient drug-free programs across the United States. We find that treatment completion and length of stay are significantly related to post-treatment employment. Holding length of stay constant, the occurrence of employment at follow-up among patients who complete their planned treatment is almost 2 times that of patients who do not complete treatment. However, treatment completion did not have a statistically significant effect on the probability of post-treatment crime. Although our results are mixed, these findings suggest that greater attention should be placed on evaluating the importance of both length of stay and treatment completion in treatment outcome studies

1: J Subst Abuse Treat. 1998 Jan-Feb;15(1):65-74. Links

Work and identity in substance abuse recovery.

Room JA.

Alcohol Research Group, Berkeley, CA 94709, USA.

Reduction in length of stay due to managed care has forced medical model treatment to focus on detoxification and "medically necessary" services at the expense of "wraparound" social services addressing employment, housing, and family problems. Lower staff and infrastructure costs enable social model programs to offer more (nonmedical) services and a longer stay at comparatively lower cost. Among the services they provide are vocational rehabilitation and job-search training, with the view that participants are better off if re-entry is mediated by sober social networks, stable environments, and employment. This paper demonstrates that employment training/job search activities are integrated into social model programs, and offers qualitative evidence of how staff and advanced residents teach the value of work. Longitudinal quantitative data collected at the same time suggest the focus of social model on employment does make a difference in posttreatment functioning: 1-year follow-up Addiction Severity Index (ASI) scores show decreases in employment problems among social model clients, along with comparable improvement on other composite scores of the ASI.

1: Subst Use Misuse. 2004;39(13-14):2309-24. Links

Effectiveness of vocational problem-solving skills on motivation and job-seeking action steps.

Coviello DM, Zanis DA, Lynch K.

Center for Studies of Addiction, University of Pennsylvania, Pennsylvania, USA.

Most research on employment interventions focuses on job acquisition as the sole outcome measure, despite the fact that there are many intermediate steps to obtaining work. This article examines the impact of a vocational problem solving skills (VPSS) intervention to increase motivation and action step activities that lead to employment. Over a 1-year period between 1995 and 1996, a sample of 109 methadone maintained treatment clients were randomly assigned to either a 10-session vocational problem solving intervention (N= 62) or a time and attention control condition (N=47). The Addiction Severity Index (ASI) and a Vocational Motivational Assessment Checklist (VMAC) were administered upon enrollment in the study and at 6 months postbaseline. The VMAC was completed on a biweekly basis over the 12-week intervention period. The VMAC measures both the behavioral actions to obtain employment (e.g., reading want ads, completing job applications) and client perceived motivation to obtain a job. There were no differences by condition in the level of motivation to secure employment and the number of job seeking activities during the intervention period. However, motivation to work and number of action steps did predict obtaining employment for the sample as a whole at the 6-month follow-up. Although the intervention did not increase motivation and job seeking activities, information regarding reasonable outcomes for this population of chronically unemployed persons was identified. Also, practical and methodological implications are discussed.

1: J Subst Abuse Treat. 2001 Jul;21(1):19-26. Links

A community-based trial of vocational problem-solving to increase employment among methadone patients.

Zanis DA, Coviello D, Alterman AI, Appling SE.

Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA. [email protected] Unemployment remains a common problem among methadone patients. This study examined the effectiveness of the Vocational Problem-Solving Skills (VPSS) intervention to help unemployed methadone patients obtain employment. METHODS: 109 patients were randomly assigned to receive 10 sessions of either VPSS (n=62) or Interpersonal Problem-Solving (IPS) (n=47). Fourteen counselors from two methadone programs were trained to deliver both the VPSS and IPS counseling sessions. RESULTS: Overall, 93% (101/109) of the patients completed a 6-month follow-up assessment which revealed that 58.6% (34/58) of patients in the VPSS condition were employed, whereas 37.2% (16/43) in the comparison condition worked (chi-square=4.53, 1 df, p<0.05). However, a multinomial regression equation found that the VPSS intervention did not significantly contribute to the prediction of employment. Other factors such as longer length of previous work experience, 40 years of age or older, treatment site, and baseline patient motivation to work emerged as significant predictors. CONCLUSION: Although VPSS alone was not a strong independent predictor of improved employment functioning, improvements in employment functioning were detected at one of the two sites as a function of VPSS

Efficacy of the customized employment supports (CES) model of vocational rehabilitation for unemployed methadone patients: preliminary results.

Staines GL, Blankertz L, Magura S, Bali P, Madison EM, Spinelli M, Horowitz E, Guarino H, Grandy A, Fong C, Gomez A, Dimun A, Friedman E.

Institute for Treatment and Services Research at National Development and Research Institutes, New York, New York 10010, USA.

This article presents initial efficacy data for an innovative vocational rehabilitation model designed for methadone-maintained patients--the Customized Employment Supports (CES) model. In this model, a CES counselor works intensively with a small caseload of patients in order to overcome the vocational as well as nonvocational barriers that hinder their employment, with the goal of attaining rapid placement in competitive employment. The CES model was implemented at two Manhattan methadone treatment programs as part of a randomized clinical trial comparing the model's employment outcomes with those of standard vocational counseling. The study tested the hypothesis that patients in the experimental group will have better employment outcomes than those in the comparison group. The data were collected from May 2001 through September 2003. The sample consisted of the first 121 patients who had completed their 6-month follow-up interviews. The preliminary results supported the hypothesis for two indices of paid employment, i.e., the CES group was more likely to obtain both competitive employment and informal paid employment. The clinical trial is continuing

Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid-dependent outpatients.

Kidorf M, Neufeld K, Brooner RK. Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. [email protected]

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, 1995). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients--a "stepped care" service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care--MSC; Brooner and Kidorf (2002) was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. 1999), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August--September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.

1: Drug Alcohol Depend. 2000 Aug 1;60(2):151-9. Links

Chemical dependency treatment and employment outcomes: results from the 'ADATSA' program in Washington State.

Luchansky B, Brown M, Longhi D, Stark K, Krupski A.

Department of Social and Health Services, Research and Data Analysis, PO Box 45204, Olympia, WA 98504-2504, USA. [email protected]

The Alcohol and Drug Addiction Treatment and Support Act (ADATSA) created a treatment program for indigent clients in Washington State. This research assesses the relationship between the level of treatment services received and subsequent employment outcomes. Clients who completed their plan of treatment earned more than those who did not, controlling for other factors. Those clients who received vocational services, in addition to completing treatment, earned more than those who completed treatment only. While on average wages were low, this study does show that clients once deemed 'unemployable' can become productive

1: J Appl Behav Anal. 2007 Fall;40(3):387-410. Links A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users.

Silverman K, Wong CJ, Needham M, Diemer KN, Knealing T, Crone-Todd D, Fingerhood M, Nuzzo P, Kolodner K.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite 142 West, Baltimore, Maryland 21224, USA. [email protected]

High-magnitude and long-duration abstinence reinforcement can promote drug abstinence but can be difficult to finance. Employment may be a vehicle for arranging high- magnitude and long-duration abstinence reinforcement. This study determined if employment-based abstinence reinforcement could increase cocaine abstinence in adults who inject drugs and use cocaine during methadone treatment. Participants could work 4 hr every weekday in a workplace where they could earn about $10.00 per hour in vouchers; they were required to provide routine urine samples. Participants who attended the workplace and provided cocaine-positive urine samples during the initial 4 weeks were invited to work 26 weeks and were randomly assigned to an abstinence-and-work (n = 28) or work-only (n = 28) group. Abstinence-and-work participants had to provide urine samples showing cocaine abstinence to work and maintain maximum pay. Work-only participants could work independent of their urinalysis results. Abstinence-and-work participants provided more (p = .004; OR = 5.80, 95% CI = 2.03-16.56) cocaine- negative urine samples (29%) than did work-only participants (10%). Employment-based abstinence reinforcement can increase cocaine abstinence.

1: Drug Alcohol Depend. 2005 Aug 1;79(2):119-28. Epub 2005 Feb 24. Links

Reinforcement-based therapy: 12-month evaluation of an outpatient drug-free treatment for heroin abusers.

Jones HE, Wong CJ, Tuten M, Stitzer ML.

Cornerstone Treatment Research Clinic, Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Cornerstone D-3-E, 4940 Eastern Avenue, Baltimore, MD 21224, USA. [email protected]

This controlled study examined the efficacy of reinforcement-based therapy (RBT) for producing enhanced abstinence outcomes over 12 months in opioid-dependent patients exiting a brief residential detoxification. Patients were randomly assigned upon completing their medically managed taper (i.e., detoxification) to RBT (N=66) or usual care (N=64) referral to community treatment programs. The 6-month RBT program offered an array of abstinence-based incentives including rent payment for recovery housing, program-led recreational activities and skills training for procuring employment. RBT produced significantly higher self-report and urinalysis-confirmed rates of abstinence from opioids and cocaine relative to usual care at 1 (42% versus 15%) and 3 (38% versus 17%) months during treatment but not at 6 or 12 months after enrollment. The RBT but not the usual care group showed significant increases in the number of days worked and the amount of legal income earned at 3, 6 and 12 months. The results of this randomized study suggest that an intensive reinforcement-based therapy that includes abstinence- based recovery housing is a promising approach; however, further research is needed to determine the role of treatment intensity and the specific efficacy of RBT's component parts

1: Subst Use Misuse. 2007;42(7):1141-59. Links

Professional demeanor of chronically unemployed cocaine-dependent methadone patients in a therapeutic workplace.

Carpenedo CM, Needham M, Knealing TW, Kolodner K, Fingerhood M, Wong CJ, Silverman K.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.

This study assesses the frequency that users of illicit drugs display unprofessional behaviors in an employment setting. This research was conducted in the therapeutic workplace, a model employment-based treatment program for chronically unemployed adults with long histories of illicit drug use in 2003. Fifty-three unemployed adults in methadone treatment, who were opiate and cocaine dependent, showed signs of injection drug use, and recently used cocaine were hired to work for 4 hours every weekday for 7 months. Results show that while the overall incidence of many undesirable behaviors is low, a small percentage of participants had serious workplace behavior problems that might limit their success in community workplaces. This study suggests that unprofessional behavior in the workplace could contribute to chronic unemployment in this population. The study's limitations are noted and future needed research is suggested.

The effectiveness of vocational services for substance users in treatment.

Magura S, Staines GL, Blankertz L, Madison EM.

National Development and Research Institutes, New York, New York 10010, USA. [email protected]

Employment appears frequently in the literature as an outcome criterion for substance users in treatment, and most clinicians subscribe to the belief that work plays an important role in recovery from addiction. Despite the importance attached to employment, the major standard treatment modalities have not been shown as effective in increasing client employment after treatment. The article presents a critical review and synthesis of three decades of research on the effectiveness of specialized vocational intervention for addiction treatment clients.

PMID: 15603001 [PubMed - indexed for MEDLIN

1: Behav Modif. 2005 Mar;29(2):417-63. Links

A web-based therapeutic workplace for the treatment of drug addiction and chronic unemployment. Silverman K, Wong CJ, Grabinski MJ, Hampton J, Sylvest CE, Dillon EM, Wentland RD.

Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA. [email protected]

This article describes a Web-based therapeutic workplace intervention designed to promote heroin and cocaine abstinence and train and employ participants as data entry operators. Patients are paid to participate in training and then to perform data entry jobs in a therapeutic workplace business. Salary is linked to abstinence by requiring patients to provide drug-free urine samples to gain access to the workplace. Prior data show that a prototype of the intervention could promote drug abstinence. Preliminary data on the Web-based intervention suggest that it should be able to teach adults with histories of chronic unemployment and drug addiction to become skilled data entry operators in about 3 to 6 months. Early experience in the business provides preliminary evidence that it might become financially successful. The therapeutic workplace intervention may serve as an effective and practical long-term treatment for chronic unemployment and heroin and cocaine addiction.

Employment outcomes for hard-to-reach persons with chronic and severe substance use disorders receiving assertive community treatment.

Gold PB, Meisler N, Duross D, Bailey L.

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA. [email protected]

Many persons with chronic and severe substance use disorders (SUDs) enter and exit public substance dependence treatment systems with limited benefit, but continue overuse of high-cost health and human services. Less than a third holds jobs, earning income below U.S. federal poverty levels. Long-term integrated substance dependency treatment, rehabilitation, and support services will be essential to resolve substance dependence and employment problems. This single-group program evaluation reports adaptation of Assertive Community Treatment (ACT), a multi-component, team-based service model originally designed for persons with severe mental illnesses and multiple disabilities, for effectiveness with persons with severe SUDs. The ACT model delivers an integrated package of treatment, rehabilitation, and support to reduce substance misuse and increase employment. Of the 35 clients admitted 12 months prior to conclusion of this 2-year service demonstration, only one left treatment prematurely. Generally, clients modestly reduced substance misuse and increased employment. However, the evaluation design and small sample limit inferences of causation and generalizability of these promising outcomes. Persuading states to adopt expensive team-based approaches for this population will require firm evidence of favorable cost-benefit ratios.

1: Exp Clin Psychopharmacol. 2003 Feb;11(1):46-55. Links Effects of reinforcer magnitude on data-entry productivity in chronically unemployed drug abusers participating in a Therapeutic Workplace.

Wong CJ, Sheppard JM, Dallery J, Bedient G, Robles E, Svikis D, Silverman K.

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA. [email protected]

The Therapeutic Workplace is a substance abuse treatment wherein patients are hired and paid to work in a job contingent on daily drug-free urine samples. The present study examined data-entry productivity of 6 unemployed methadone patients who demonstrated relatively variable and low data-entry response rates. A within-subject reversal design was used to determine whether increasing reinforcement magnitude tenfold could increase response rates. Four of the 6 participants showed the highest rates of responding in the high magnitude reinforcement condition. Two participants, who had the lowest overall response rates, showed less robust changes to the magnitude manipulation. The results suggest that reinforcement magnitude can be used to improve productivity in Therapeutic Workplace participants.

1: Am J Public Health. 1991 Jul;81(7):904-7.

The impact of time in treatment on the employment and earnings of drug abusers.

French MT, Zarkin GA, Hubbard RL, Rachal JV.

Health and Human Resource Economics, Research Triangle Institute, NC 27709-2194.

We use data from a longitudinal survey to estimate the effects of time in drug abuse treatment on post-treatment weeks worked and earnings for 2,420 clients in three treatment modalities. The regression analysis shows that time in treatment had a positive and statistically significant impact on these labor market outcomes, but the effects were small for all modalities. Although residential clients experienced the largest relative changes in weeks worked and real earnings, a benefit-cost calculation suggests that additional residential treatment cannot be justified from earnings improvements alone. These results may indicate a need for more employment services while in treatment.

Learning from disappointing outcomes: an evaluation of prevocational interventions for methadone maintenance patients.

Lidz V, Sorrentino DM, Robison L, Bunce S.

Department of Psychiatry, Drexel University College of Medicine, Institute for Addictive Disorders, Philadelphia, PA 19102-1192, USA. [email protected]

To increase rates of employment and improve overall rehabilitation in methadone maintenance treatment, three prevocational trainings, Vocational Problem Solving, Job Seekers Workshop, and the two combined, were evaluated as adjunctive services. Between March 1995 and April 1998, subjects in treatment were interviewed at baseline, randomly assigned to one of the trainings, and followed up at 6 and 12 months postbaseline. None of the three models produced significantly greater employment or better overall rehabilitation. Experience from the study suggests that closer integration of prevocational training with treatment, individualizing efforts to meet training needs, and providing support during job-finding and early job-holding might improve program effectiveness.

The impact of employment counseling on substance user treatment participation and outcomes.

Reif S, Horgan CM, Ritter GA, Tompkins CP.

Schneider Institute for Health Policy, Heller School, Brandeis University, Waltham, Massachusetts 02454-9110, USA. [email protected]

The nationally representative Alcohol and Drug Services Study (ADSS, 1996--1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N=988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted.